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Biological psychiatry's false paradigm

Days before the official May 22 publication date of the "Diagnostic and Statistical Manual of Mental Disorders" (DSM-5), a number of psychiatrists who were closely associated with the project scrambled to do some preemptory damage control, mostly by lowering the expectations for what was to come.

Michael B. First, professor of psychiatry at Columbia, acknowledged on NPR that there was still no empirical method to confirm or rule out any mental illness. "We were hoping and imagining that research would advance at a pace that laboratory tests would have come out. And here we are 20 years later and we still unfortunately rely primarily on symptoms to make our diagnoses." Speaking to The New York Times, Thomas R. Insel, director of the National Institutes of Mental Health, insisted that this failure had not been for lack of effort.

In the same Times article, David J. Kupfer, chairman of the DSM-5 Task Force, admitted "a failure of our neuroscience and biology to give us the level of diagnostic criteria, a level of sensitivity and specificity that we would be able to introduce into the diagnostic manual." Drs. Kupfer, Insel and First agree that the new paradigm envisioned for psychiatry — the reason the new edition was undertaken — remains elusive.

By 1980, the creators of the DSM believed implicitly that neuroscience would reveal the biological roots of every mental illness. This advance, they claimed, would obviate the need to determine the meaning of symptoms, a process they considered subjective and unreliable. The new paradigm would have put the diagnosis of mental illness on the same empirical footing as medical illnesses such as diabetes, heart disease and cancer — a major goal of biological psychiatry, which seeks parity of esteem and funding with other medical specialties.

The DSM-III, the DSM-IV and now the DSM-5 made no provision for the clinician to consider the origin or meaning of symptoms that comprised the checklists given for diagnosing a mental illness. The justification offered for this omission, in addition to the certainty that markers for a biological substrate would identify each illness, was that diagnosing with symptoms of unspecified meaning would promote better agreement among clinicians (reliability) in diagnosis and research. This, in fact, did not happen.

Ultimately, the DSM has failed because its creators, focusing mostly on the brain, did not understand that a human being is, in essence, freedom, and may under pressure deny or misuse that freedom in ways that incline emotion, thought and behavior to fall outside the boundaries set by the arbiters of mental normalcy.

As if to sound the death knell for the role of freedom in the development of mental illness, the DSM-5 eliminated the Axis-1/Axis-2 distinction introduced in the DSM-III (1980), which at least acknowledged that some illnesses were of psychological origin. In the DSM-5, all mental illnesses are taken to be brain diseases.

Adolf Meyer, chief of psychiatry at Johns Hopkins from 1910 to 1941, believed that most mental illnesses, including some schizophrenias, are not brain diseases but the consequence of defensive psychological reactions to difficult or traumatic life events that people fail to handle adaptively, often by denying their freedom to do so.

Meyer named his approach psychobiology — a radically different concept of mental illness than biological psychiatry — intending to acknowledge both mind and brain in the development of these illnesses. Though he felt that biology is not the cause of most pathological disturbances of mental life, he reasoned that the brain neural substrate is altered in the psychobiological reaction from which such an illness emerges. Meyer believed that what we experience in the world, with others, can change our brains, and not always for the better.

During the last century and a half, convincing psychological explanations have been tendered for many mental illnesses, Meyer's psychobiology providing some of the most substantial. Nonetheless, it would be anathema to suggest that what we now know about these illnesses is all we will ever know.

No one now — not clinicians, not patients, and certainly not managed care organizations and pharmaceutical companies — wants to hear this. But if, in 10 or 20 years, no biological explanation for the major mental illnesses is in sight, the search for what remains unexplained after a satisfactory psychological understanding is in hand may come to be seen as having been a phantom all along.

Meanwhile, the efforts to explain mental illness at the molecular level, whatever this might entail, will continue. And, no doubt, so will the habit of using past failures to justify and fund the pursuit of future failures.

René J. Muller, a psychologist, is the author, most recently, of "Doing Psychiatry Wrong." He is working on an approach to diagnosing mental illness based on the psychobiology of Adolf Meyer. His email is mullerrenej@aol.com.  

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